Primary Care Coding Alert

Question: Our physician saw a patient in the hospital. The patient had only Part A Medicare coverage, and had an HMO as her secondary insurer. Medicare Part A does not cover physician services, so we billed the HMO for our FP's work. But the HMO refuses to pay and tells us to bill the primary insurer first. What should we do?


Georgia Subscriber


Answer: You-ll have to track down a contact at the HMO and talk to them over the phone. Tell the claims representative that the patient only has Medicare Part A, which does not cover physicians- services in the hospital, and that's why the HMO insurance company is technically the -primary- payer for this service.

If the HMO still refuses to do business with you, consider submitting the claim to the patient's Part A insurer, Medicare, just so you can get the denial. Then bill the HMO again for the service, along with a copy of the Medicare denial. Explain that the physician's service was not covered by the patient's primary insurer (Medicare) and that you are therefore requesting payment for the work.